Apparatus for performing diagnostic and therapeutic modalities in the biliary tree

ABSTRACT

Catheter apparatus for performing diagnostic and therapeutic modalities in the biliary tree includes a catheter with multiple lumens. A first lumen is adapted to receive a guidewire and can serve as a transport lumen for contrast agent. A second lumen carries a cutting wire for performing a sphincterotomy. A third lumen can be used as an inflation lumen for a distally located balloon. Expansion of the balloon occludes a portion of the biliary tree and allows the catheter to sweep any gallstones through the sphincter of Oddi into the duodenum.

CROSS REFERENCE TO RELATED APPLICATION

This is a continuation application of our U.S. patent application Ser.No. 08/648,356 filed May 14, 1996 for an Apparatus for PerformingDiagnostic and Therapeutic Modalities in the Biliary Tree that is acontinuation of our U.S. patent application Ser. No. 08/242,168 filedMay 13, 1994 for an Apparatus for Performing Diagnostic and TherapeuticModalities in the Biliary Tree now U.S. Pat. No. 5,547,469 issued Aug.20, 1996.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention generally relates to apparatus that is useful inperforming diagnostic and therapeutic modalities in the biliary tree andmore particularly to apparatus that is adapted for facilitating thediagnosis of gallstones in the bile duct and other portions of thebiliary tree and the removal of such gallstones.

2. Description of Related Art

Historically the migration of gallstones into an individual's commonbile duct was corrected by general surgical procedures. A surgeon wouldincise the bile duct and remove the gallstones and normally remove thegallbladder. In recent years less invasive treatment modalities havereplaced these general surgical procedures and reduced patient trauma,long hospital stays and recovery periods.

For example, U.S. Pat. Nos. 4,696,668 and 4,781,677, both to Wilcox,disclose a treatment modality involving the administration of adissolution agent in the bile duct to essentially dissolve anygallstones. More specifically, a catheter contains several lumens forinflating and deflating each of two balloons, venting bile, and infusingand aspirating the dissolution agent. Inflating the balloons occludesthe bile duct at two spaced sites and creates a sealed spaced thatreceives the dissolution agent. As the space is sealed from theremaining biliary tree, the dissolution agent finds access to thegallbladder and any gallstones therein through the cystic duct with theexclusion of bile from the gallbladder fundus. The dissolution agentalso will be confined in high concentration around bile duct gallstones.After the gallstones dissolve the balloons are deflated and the cathetercan be withdrawn. In this particular approach, the catheter is directedinto the biliary tree using a standard duodenoscope that passes throughthe alimentary tract. Although this and analogous approaches have thepotential of minimizing patient trauma, such treatments require extendedplacement of the duodenoscope in the patient, exhibit low efficacy andintroduce a potential for adverse reactions to the dissolution agents.

In an alternative approach, a surgeon directs a surgical extractor intothe biliary tree through at least an incision in the bile duct. Forexample, in U.S. Pat. No. 3,108,593 to Glassman a surgeon incises boththe bile duct and duodenum. Then the surgeon directs an extractorthrough the bile duct incision, biliary tree, sphincter of Oddi andduodenum to exit through the duodenum incision. This extractor includesa series of longitudinally spaced cages for trapping any gallstones inthe bile duct and removing them through either of the incisions.

U.S. Pat. No. 4,627,837 to Gonzalo discloses a catheter device with apair of inflatable balloons at its distal end. This catheter is ledthrough an incision in the bile duct toward the duodenum. After thedistal balloon passes through the sphincter of Oddi, both balloons areexpanded to anchor the catheter in place. This enables the catheter tobe used for irrigating and flushing through other lumens in order tocapture any gallstone in the second balloon for removal through theincised bile duct.

In accordance with still another modality as for the treatment ofstrictures, a surgeon may insert a catheter device through the bile ductor duodenum for the purpose of dilating or enlarging the sphincter ofOddi. For example, U.S. Pat. No. 4,705,041 to Kim discloses a dilatorthat is directed through an incision in the bile duct and the sphincterof Oddi. An expandable tip dilates the sphincter of Oddi. U.S. Pat. No.5,035,696 to Rydell discloses an electrosurgical instrument that isdirected through the duodenum and to the sphincter of Oddi forperforming a sphincterotomy. This apparatus contains a cutting wire thatis heated to cut the sphincter muscle. U.S. Pat. No. 5,024,617 toKarpiel, discloses a similar device that can be directed through aduodenoscope. U.S. Pat. No. 5,152,772 to Sewell, Jr. discloses a devicefor performing a sphincterotomy that is directed through an incision inthe bile duct and includes a knife for cutting the sphincter muscle.

The use of the duodenoscope and sphincterotomy devices, such as shown inthe Rydell and Karpiel patents, enables an internist to diagnose andtreat problems in the biliary tree with minimal patient invasion. Forexample, modalities as described in these patents eliminates the surgeryneeded for incising the bile duct. Consequently, these modalities can beperformed as outpatient or day surgical procedures. These proceduresgreatly reduce patient trauma, the length of a hospital stay andrecovery times. For example, if an internist determines that gallstonesare present in the biliary tree, particularly the common bile duct, theinternist can insert a duodenoscope into the duodenum to view thesphincter of Oddi. Then a first catheter can be advanced through theworking channel of the duodenoscope with or without a guidewire anddirected through the sphincter of Oddi into the biliary tree. Contrastagent injected through the catheter enables fluoroscopy or other imagingprocedures to confirm the presence of gallstones within the biliarytree. Next the internist exchanges the first catheter for a secondcatheter for performing a sphincterotomy such as the types disclosed inthe above-identified Rydell and Karpiel patents. The second catheter isthen exchanged for a third catheter such as shown in the Glassman patentor some other equivalent retrieval catheter for drawings gallstonesthrough the enlarged sphincter of Oddi. Thereafter the retrievalcatheter is manipulated to release the gallstone into the duodenum. Thecatheter, any guidewire and the duodenoscope can then be removed tocomplete the procedure.

This procedure is significantly less traumatic to the patient than otherprior art procedures because the only incision occurs during thesphincterotomy. However, this procedure as presently practiced requiresthree separate catheters and two catheter exchanges. These exchanges arerequired because the first, second and third catheters function solelyto inject contrast agent to perform the sphincterotomy and to dislodgegallstones, respectively. The time required for performing each catheterexchange can increase patient trauma and increase the duration of theprocedure and reduce efficiency. Moreover, each such procedure requiresthe use of two or three separate catheter devices.

SUMMARY

Therefore, an object of this invention is to provide apparatus forperforming both diagnosis and additional therapeutic treatment withoutrequiring a catheter exchange.

Another object of this invention is to provide apparatus for performingdiagnosis and treatment in the biliary tree that can reduce patienttrauma.

Yet another object of this invention is to provide apparatus thatenables the removal of gallstones from the biliary tree by a procedurethat reduces the number of required catheters and catheter exchanges.

Still another object of this invention is to provide a single catheterapparatus that can perform a sphincterotomy and remove gallstones in thecommon bile duct.

Yet another object of this invention is to provide a single catheterapparatus that can perform a sphincterotomy and inject contrast materialinto the biliary tree.

Still yet another object of this invention is to provide a singlecatheter apparatus that can inject contrast agent into biliary tree,performing a sphincterotomy and remove gallstones in the bile duct intothe duodenum.

In accordance with one aspect of this invention, apparatus can be usedin a treatment modality including an enlargement procedure and anotherprocedure to be performed. This apparatus includes a catheter withproximal and distal ends and proximal and distal portions. The catheterincludes first, second and third generally parallel lumens. The firstlumen has a greater diameter than either of the second and third lumensand the lumens each extend between proximal and distal portions of thecatheter. The apparatus for performing the enlargement procedure extendsthrough the second lumen for operating distally of the catheter inresponse to manipulations of an operator at the proximal end of thecatheter. The first lumen has a proximal port for enabling access to thefirst lumen and the third lumen has a proximal port and a distal portfor enabling the remote control of some other procedure.

In accordance with another aspect of this invention, apparatus isprovided for removing objects from the biliary tree. This apparatusincludes a catheter that is directed through the working channel of aduodenoscope and the sphincter of Oddi into the biliary tree. Thecatheter includes first, second and third lumens with the first lumenbeing larger than either the second or third lumens and the lumensgenerally extending between proximal and distal portions of the catheteralong parallel axes. Apparatus for cutting the sphincter of Oddiincludes a cutting wire extending through the second lumen andexternally of the catheter means through a distal port along a lengththat is coextensive with part of the distal portion of the catheter. Ahandle attaches to the catheter at the proximal portion and to theproximal wire portion to control the position and orientation of thecutting wire. An expansible balloon is mounted on the distal portionspaced from the cutting wire and can be inflated through the third lumenin order to move any gallstone in the biliary tree through the enlargedsphincter of Oddi.

In accordance with still another aspect of this invention, the apparatusis provided for directing contrast agent into the biliary tree andperforming a sphincterotomy through the working channel of aduodenoscope. This apparatus includes a catheter that is directedthrough the working channel of the duodenoscope and the sphincter ofOddi into the biliary tree. The catheter includes first, second andthird lumens with the first lumen being larger than either the second orthird lumens and the lumens generally extending between proximal anddistal portions of the catheter along parallel axes. Apparatus forcutting the sphincter of Oddi includes a cutting wire extending throughthe second lumen and externally of the catheter means through a distalport along a length that is coextensive with part of said distal portionof the catheter. A handle attaches to the catheter into the proximalwire portion to control the position and orientation of the cuttingwire. The proximal port of the third lumen connects to a contrast agentsource and the third lumen delivers contrast agent into the biliary treethrough a distal port in the distal end of the catheter.

BRIEF DESCRIPTION OF THE DRAWINGS

The appended claims particularly point out and distinctly claim thesubject matter of this invention. The various objects, advantages andnovel features of this invention will be more fully apparent from areading of the following detailed description in conjunction with theaccompanying drawings in which like reference numerals refer to likeparts, and in which:

FIG. 1 is a plan view of one embodiment of apparatus constructed inaccordance with this invention;

FIG. 2 is a cross-section taken along lines 2—2 in FIG. 1;

FIG. 3 is a cross-section taken along lines 3—3 in FIG. 2;

FIG. 4 is a cross-section taken along lines 4—4 in FIG. 2;

FIG. 5 depicts the apparatus of FIG. 1 positioned through a duodenoscopefor injecting contrast agent into the biliary tree.

FIG. 6 is an enlarged view that depicts the orientation of the apparatusin FIG. 1 for performing a sphincterotomy;

FIG. 7 depicts the apparatus of FIG. 1 positioned through a duodenoscopefor dislodging material within the common bile duct;

FIG. 8 is a cross-section of an alternative embodiment of the apparatusas viewed generally along lines 3—3 in FIG. 2; and

FIG. 9 is a cross-section of still another embodiment of this inventiontaken along lines 3—3 in FIG. 2.

DESCRIPTION OF ILLUSTRATIVE EMBODIMENTS

FIG. 1 depicts a catheter apparatus 10 that has the capability ofinjecting a contrast agent into the biliary tree, of performing asphincterotomy and of dislodging a gallstone into the duodenum. Theapparatus 10 includes a catheter 11 which, for purposes of definition,includes a proximal end portion 13 extending from a proximal end 12 anda distal end 14 with a distal portion 15 extending a short distance fromthe distal end 14. In a typical application, the catheter will have aworking length of 200 cm and the distal end portion 15 will have alength of 6 cm to 9 cm. Normally the distal portion 15 will have adiameter that is smaller than the diameter of the proximal portion toincrease the flexibility of the distal portion 15. The reduction indiameter also makes the tip less traumatic and allows the tip portion toreach smaller passages while allowing the larger proximal portion toprovide necessary hoop strength and rigidity, particularly where theproximal portion 13 is coextensive with the working channel of aduodenoscope. For example, the proximal and distal portions might havediameters corresponding to 7 Fr and 5.5 Fr catheter sizes (i.e., 0.09″and 0.07″ respectively).

As shown particularly in FIG. 2, the catheter 11 has three lumens. Afirst lumen 16 has a diameter that is greater than either a second lumen17 or a third lumen 20. In one particular embodiment the lumen 16 has adiameter of 0.040″ in the proximal portion 13 that reduces to about0.037″ in the distal portion 15 to receive a standard 0.035″ guidewire.In addition the lumen 16 is offset from the center of the catheter 11.

The lumens 17 and 20 are each smaller in diameter than the lumen 16 andare radially offset from the centerline of the catheter, from each otherand from the lumen 16. In one particular embodiment the lumens 17 and 20each have internal diameters of 0.028″ in the proximal portions 13 thatreduces to about 0.020″ in the distal portion 15. As described later,this lumen 20 carries a cutting wire for performing a sphincterotomy andfor allowing the infusion of a contrast agent at reasonable rates. Theangular spacing between the lumens 17 and 20 is about 45° and theangular spacing between the first lumen 16 and each of the lumens 17 and20 each is about 157.5°. In this configuration and with these dimensionsthe proximal portion 13 readily passes through the working channel ofany duodenoscope.

Referring again to FIGS. 1 and 2, each of the lumens 16, 17 and 20includes an entry port in the proximal portion 13 and an exit port inthe distal portion 15. Generally, and as described in more detail later,the first lumen 16 has an exit port through the distal end 14 while theexit ports for the lumens 17 and 20 can be sited at different locationsin the distal portion 15 depending upon a particular application.

In FIG. 1, the entry ports in proximal portion 13 adjacent the proximalend 12 include an entry port 21 that provides access to the lumen 16 andincludes an optional Leur lock fitting 22. A proximally positioned entryport 23 provides access to the lumen 17 and includes an optional Leurlock fitting 24. A proximal entry port 25 for the lumen 20 is locatedcoextensively with a portion of a handle 26 attached to the proximal end12.

Referring to the distal end portion 15, the catheter 11 in thisparticular embodiment carries an expansible balloon 30 proximally of theexcursion of a cutting wire 31 externally of the catheter 11. As shownin FIG. 3, the lumen 17 emerges at a distal exit port 32 through theside of the catheter 11 with the interior of the expansible balloon 30.An extension of the lumen 17 beyond the distal port 32 is sealed byknown methods of manufacture. Consequently, fluid forced through theentrance port 23, as by a syringe (not shown) attached to the Leur lockfitting 24, expands the balloon 30 into an occluding orientation asshown in FIG. 3 with an inflated diameter in the range up to 20 mm.

As will also be apparent from viewing FIGS. 3 and 4, the first lumen 16extends through the catheter 11 and terminates with an exit port 33 inthe distal end 14. Thus the lumen 16 is adapted for receiving aguidewire through the entrance port 21 that will extend through thecatheter 11 and exit the distal end 14 and allow the catheter to slideover that guidewire.

Referring to FIG. 4, a distal end 34 of the cutting wire 31 attaches toa clamp 35 formed at the distal end of the lumen 20. Spaced skived ports36A and 36B allow an active portion 37 of the cutting wire 31 to emergefrom the catheter 11 through the skived aperture 36A, parallel thecatheter 11 exteriorly thereof and return into the lumen 20 through theport 36B and a reinforcing sleeve 38. The cutting wire 31 then extendsthrough the lumen 20 to the handle 26 shown in FIG. 1 where it emergesas a proximal end portion 40.

The handle 26, as shown in FIG. 1, includes a central member 41terminating with a thumb ring 42. The central member 41 extends throughand slides with respect to a body section 43 having opposed finger rings44. The central member 41 also attaches to the catheter 11, and istherefore an extension of the catheter 11. The member 43 additionallyincludes an internal connector 45 for clamping the proximal end 40 ofthe cutting wire 31. Thus, when the body 43 is at its distal position asshown in FIG. 1, the distal portion of the catheter 15 is in essentiallystraight line as shown in FIG. 1 with the active portion 37 of thecutting wire 31 being closely adjacent the catheter 11. Retracting thebody portion 43, causes the cutting wire 31 to bend the distal endupwardly as shown in FIG. 1 to a position that is essentially at rightangles to the main axis of the catheter, as will be shown later.

The connector block 45 and the cutting wire 31 are generally conductivemembers that attach through an RF connector 46 to an RF heating source47. The use of such RF heating sources 47 for energizing a cutting wire31 thereby to cut the sphincter muscle is well known in the art andrepresents one possible sphincterotomy procedure that can be adapted forthe apparatus of this invention and is not described further.

With this description of the apparatus structure, it will now bepossible to understand its use in a particular application. FIG. 5discloses, in a partially broken and schematic view, the positioning ofa duodenoscope 50 in the duodenum 51 adjacent the sphincter of Oddi 52.A catheter 11 such as constructed in FIG. 1 passes through the sphincterof Oddi 52 into the common bile duct 53, bypassing the pancreatic duct54. The distal end 14 does not extend to the gallbladder 55.

Fluoroscopy allows the appropriate positioning by utilizing a series ofradio-opaque markers 56 at the distal portion 15 that may include theclamp 35 and the reinforcing sleeve 38 in FIG. 4. The catheter 11 can bepositioned with or without the presence of a guidewire 57 in the lumen16 shown in FIGS. 2, 3 and 4. For purposes of injecting the contrastagent, any guidewire 57 can be withdrawn to allow the contrast agent tobe injected through the lumen 16 for purposes of fluoroscopicexamination to confirm the presence of one or more gallstones 58. It isalso possible during the operation to expand the balloon 30 to occludethe bile duct 53 and block any migration of contrast agent into theduodenum 51 or the pancreatic duct 54.

FIG. 6 is an enlarged view showing the duodenum 51, sphincter of Oddi52, portions of the pancreatic duct 54 and the common bile duct 53. InFIG. 6 the catheter 11 has been positioned relative to the duodenoscope50 through the opening of the sphincter of Oddi 52. The handle 43 inFIG. 1 has been drawn proximally to deflect the distal portion 15 intoessentially a right angle configuration such that the cutting wire 31abuts a portion of the sphincter of Oddi 52. The application of RFheating to the cutting wire 31 then will cut the sphincter of Oddi 52and enlarge the opening therethrough. As will be apparent, thesphincterotomy is performed with direct visualization of the sphincterof Oddi through the duodenoscope.

Moreover, as has been observed by others, catheters having guidewire andcutting wire lumens tend to assume a particular angular orientation whenthe distal portion 15 emerges from the duodenoscope. This orientation isessentially independent of the angular position of the catheter when itis inserted into the duodenoscope. The offset nature of the lumen 20 asshown in FIG. 2, improves the location of the cutting wire 31 as thedistal portion 15 passes through the sphincter of Oddi 52. Specificallythe angularly offset brings the cutting wire 31 into better alignmentwith the common bile duct 53 and displaces the cutting wire from thepancreatic duct 54.

FIG. 7 depicts the catheter after the sphincterotomy and after thecatheter 11 is advanced over the guidewire 57, if used. FIG. 7 alsodiscloses the catheter 11 after the balloon 30 has been moved beyond agallstone 58 in the bile duct 53. The balloon 30 is expanded so thatupon withdrawal of the catheter 11 the balloon 30 will dislodge thegallstones 57 and sweep them through the sphincter of Oddi 52 into theduodenum 51.

As will now be apparent from the description of the particular catheterapparatus 10 shown in FIG. 1 and its use as discussed with respect toFIGS. 5, 6, and 7, the single catheter apparatus of this invention iscapable of providing diagnostic contrast agent injection, of performinga sphincterotomy and of dislodging gallstones in the common bile duct orother portions of the biliary tree without having to exchange acatheter. Moreover, positioning and sizing of the lumens enables thesefunctions to be performed with a catheter apparatus that is readilyadapted for use in the working channels of standard duodenoscopes.Consequently the gallstones can be removed from the biliary tree withoutbile duct incisions and accompanying surgical procedures, asduodenoscope can be introduced through the alimentary tract.Consequently the entire procedure is adapted for being performed morerapidly than prior art procedures and with fewer components. The neteffect is to reduce patient trauma and the overall time and cost ofconducting the procedure.

In FIG. 1 the balloon 30 is located proximally of the cutting wire 31.FIG. 8 discloses an alternative embodiment in which a balloon 60 islocated distally of the cutting wire 31. More specifically, the distalend of a lumen 17A, corresponding to the lumen 17 in FIGS. 3 and 4, issealed. A side facing exit port 61 skived or otherwise formed in thecatheter 11 opens into a chamber 62 formed by the balloon 60. A firstsealing portion 63 and a sealing portion 64 of the balloon 60 connectproximally and distally of the aperture 61 respectively and seal thechamber 62.

Introduction of a balloon inflation fluid through the lumen 17A expandsthe balloon 60 into an occluding orientation corresponding to theorientation of the balloon 30 shown in FIG. 3. Retraction of thecatheter 11 with the distal balloon 60 inflated enables withdrawal of agallstone from the bile duct. This particular embodiment is particularlyadapted when it is determined that a gallstone is located high in thebiliary tree to minimize the incursion of the distal portion 15 throughthe biliary tree beyond the gallstone or in any application in which theinternist desires to minimize the length of the distal portion 15 thatextends beyond the occluding balloon.

FIG. 9 discloses another embodiment of this invention for enlarging thesphincter of Oddi and performing another procedure, such as injecting acontrast agent into the biliary tree, as might be used in the diagnosisand treatment of a stricture in the biliary tree. In this particularembodiment an exit port 65 from the lumen 17B is located in the distalend 14 of the distal portion 15. The lumen 16 then can be used for aguidewire and the lumen 17B, for injecting the contrast agent directlyinto the biliary tree while the guidewire remains in place. Theapparatus would then be positioned to perform a sphincterotomy withouthaving to exchange a catheter should the procedure be warranted.

As still another alternative, the internist could utilize a conventionalcatheter for purposes of injecting the contrast agent to determine theneed for gallstone removal. If treatment were indicated, the internistcould then utilize apparatus as shown in FIG. 1 with a single exchangeover the guidewire that would pass through the lumen 16 as previouslydescribed.

Therefore, it will now be apparent that apparatus constructed inaccordance with this invention attains the several objects and theadvantages of this invention. More particularly, catheter apparatusconstructed in accordance with this invention allows the injection of acontrast agent, the performance of a sphincterotomy and dislodginggallstones from the common bile duct through the enlarged sphincter ofOddi into the duodenum all without requiring any catheter exchanges.Moreover, this apparatus allows such a procedure to occur through aduodenoscope to minimize patient trauma. The use of a single catheterwith an elimination of catheter exchanges further reduces the time andcosts associated with the use of multiple, single-function catheterdevices.

As will be apparent from the foregoing description, many alterations canbe made to the specifically disclosed embodiments. Different balloonstructures can be used and located at alternative positions. Differentcutting wire embodiments and orientations can be used. Thus, althoughthis invention has been disclosed in terms of certain embodiments, itwill be apparent that many modifications can be made to the disclosedapparatus without departing from the invention. Therefore, it is theintent of the appended claims to cover all such variations andmodifications as come within the true spirit and scope of thisinvention.

What is claimed as new and desired to be secured by Letters Patent ofthe United States is:
 1. A multi-lumen catheter for treatment of apatient, the catheter extending from a proximal end to a distal end andhaving a proximal portion, a distal portion, and a central axis, thecatheter comprising: a first lumen, a second lumen, and a third lumen;wherein each lumen extends from the proximal end to the distal endgenerally in parallel and has an entry port at the proximal portion andan exit port at the distal portion; said first lumen having a firstdiameter that is larger than a diameter of either the second lumen orthe third lumen; said first lumen having a first central axis that isradially offset from the central axis of the catheter; and wherein saidcatheter has a gradually reducing diameter in a direction from theproximal end to the distal end.
 2. The multi-lumen catheter of claim 1,wherein the first lumen is adapted to receive a guide wire.
 3. Themulti-lumen catheter of claim 1, wherein the second lumen is adapted toreceive fluid from the entry port to be discharged at the exit port forexpanding an expansible balloon provided at the distal portion.
 4. Themulti-lumen catheter of claim 1, wherein: the third lumen is adapted toreceive a cutting device for cutting a patient's internal tissue; andthe catheter further comprises an actuator connectable to the cuttingdevice at the proximal end of the catheter for actuating the cuttingdevice.
 5. The multi-lumen catheter of claim 4, wherein the third lumenincludes at least one port at the distal end adapted to expose a distalportion of the cutting device that is extendable exterior of the thirdlumen by operation of the actuator.
 6. The multi-lumen catheter of claim4, wherein the actuator is connected to an energy source for energizingthe cutting device.
 7. The multi-lumen catheter of claim 6, wherein saidenergy source is a heating source to heat said cutting device.
 8. Amulti-lumen catheter for treatment of a patient, the catheter extendingfrom a proximal end to a distal end and having a proximal portion and adistal portion, the catheter comprising: a first lumen being adapted toreceive a guiding device for guiding insertion of the catheter into abody cavity of the patient; a second lumen having an entry port at theproximal portion and an exit port at the distal portion, the secondlumen including an expansible device at the exit port; a third lumenbeing adapted to receive an operating device for performing an operationon the patient; and wherein said catheter has a gradually reducingdiameter in a direction from the proximal end to the distal end.
 9. Themulti-lumen catheter of claim 8, wherein the expansible device includesan inflatable balloon adapted to receive fluid from the entry port ofthe second lumen to be discharged at the exit port for expanding theinflatable balloon.
 10. The multi-lumen catheter of claim 8, whereinsaid first lumen includes a first diameter that is larger than adiameter of either the second lumen or the third lumen.
 11. Themulti-lumen catheter of claim 8, wherein the first lumen has a firstcentral axis that is radially offset from a central axis of thecatheter.
 12. The multi-lumen catheter of claim 8, wherein: theoperating device is a cutting device for cutting an internal tissue ofthe patient; and the catheter further comprises an actuator connectableto the cutting device at the proximal end of the catheter for actuatingthe cutting device.
 13. The multi-lumen catheter of claim 12, whereinthe third lumen includes at least one port at the distal end adapted toexpose a distal portion of the cutting device that is extendableexterior of the third lumen by operation of the actuator.
 14. Themulti-lumen catheter of claim 12, wherein said actuator is connected toan energy source for energizing the cutting device.
 15. The multi-lumencatheter of claim 14, wherein said energy source is a heating source toheat said cutting device.
 16. A method of removing an object from aninternal passage of a patient, the method comprising the steps of:inserting a catheter into the passage, the catheter having a first lumenand a second lumen each extending therethrough from a distal endinserted within the patient to a proximal end to remain exterior thepatient, the first lumen being adapted to receive a guiding device, andthe second lumen being provided with an expansible device provided nearthe distal end thereof and an entry port provided near the proximal endthereof, said catheter having a gradually reducing diameter from aproximal end to a distal end; using the guiding device to position thecatheter within the passage until the expansible device passes beyondthe object to be removed; expanding the expansible device; andwithdrawing the catheter from the patient while the expansible device isexpanded to dislodge the object from the internal passage of thepatient.
 17. The method of claim 16, wherein the guiding device includesa guidewire.
 18. The method of claim 16, wherein the expandable deviceincludes an inflatable balloon and the expanding step includes injectinga fluid through the entry port of the second lumen to inflate theinflatable balloon.
 19. The method of claim 16, further comprising thestep of removing an obstruction within the passage to enlarge a workingarea within the patient.
 20. The method of claim 19, wherein: thecatheter further includes a third lumen adapted to receive a cuttingdevice at the distal end, and an actuator connectable to the catheter atthe proximal end to actuate the cutting device; and the removing step isperformed by actuating the actuator and cutting the obstruction usingthe cutting device.
 21. The method of claim 20, wherein the cuttingdevice includes a cutting wire, a distal portion of which being exteriorto the third lumen and extendable by actuating the actuator.
 22. Themethod of claim 21, wherein heat is applied to the cutting wire to cutthe obstruction.
 23. The method of claim 16, further comprising the stepof positioning the catheter through fluoroscopy.
 24. The method of claim23, wherein the catheter includes markers at the distal end.
 25. Amulti-lumen catheter for treatment of a patient, the catheter extendingfrom a proximal end to a distal end and having a proximal portion, adistal portion and a central axis, the catheter comprising: a firstlumen, a second lumen and a third lumen; wherein each lumen extends fromthe proximal end to the distal end generally in parallel and has anentry port at the proximal portion and an exit port at the distalportion; said first lumen having a first diameter that is larger than adiameter of either the second or third lumen; said first lumen having afirst central axis that is radially offset from the central axis of thecatheter and where said first lumen is adapted to receive a guidewire;said third lumen is adapted to receive a cutting device for cutting apatient's internal tissue; and the catheter further comprises anactuator connectable to the cutting device at the proximal end of thecatheter for actuating the cutting blade.
 26. The multi-lumen catheterof claim 25, wherein said catheter has a gradually reducing diameter ina direction from the proximal end to the distal end.
 27. The multi-lumencatheter of claim 25, wherein the second lumen is adapted to receivefluid from the entry port to be discharged at the exit port forexpanding an expansible balloon provided at the distal portion.
 28. Themulti-lumen catheter of claim 25, wherein the third lumen includes atleast one port at the distal end adapted to expose a distal portion ofthe cutting device that is extendable exterior of the third lumen byoperation of the actuator.
 29. The multi-lumen catheter of claim 25,wherein the actuator is connected to an energy source for energizing thecutting device.
 30. The multi-lumen catheter of claim 29, wherein saidenergy source is a heating source to heat said cutting device.